Melanoma: Prevention, Detection, and Treatment

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Melanoma: Prevention, Detection, and Treatment

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When is a mole a problem? What do melanomas look like? Are tanning salons OK? How can melanoma be prevented? With the increased incidence of melanoma (up 2000% since 1930), you need to know the answers to these questions and more.DuPont Guerry, MD, joined us for a closer look at prevention, detection, and treatment of melanomas on June 22, 2005.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live, Dr. Guerry. Thank you for joining us today. The increase in the incidence of melanoma is startling -- 2000% since 1930. To what do you attribute this increase?

GUERRY:
I suspect it's a combination of more people getting more sun, particularly 20 or 30 years ago, because you pay now for the sun that you got in the past. So much of it is due to what we know to be the major cause of melanoma, that is, sun exposure, particularly on white skin that has not been previously exposed to sun. So it's likely big blasts of sunlight in childhood that increases the risk of melanoma later in life. That's not to say it's not the sun you got five or 10 years ago, that also makes a contribution.

Another piece of this may be that we are better at recognizing melanomas, so some of the increase is because we have found early melanomas that we used to ignore.

MODERATOR:
If we were exposed as children 20, 30, 40 years ago, is there anything we can do now to prevent melanoma?

"The thing to do as an individual is to look at your skin from top to bottom, often with the aid of a friend, companion, partner, spouse, interested individual, once a month, looking for things that are different, odd or changing."

GUERRY:
Sure. Although things may have been set in motion 20, 30 or 40 years ago, the train goes faster if you add more fuel, so continuing to moderate sun exposure will likely decrease the likelihood of getting melanoma. So it isn't all what you got back in childhood.

Another piece of the puzzle is learn to examine your own skin for suspicious changing spots that are often pigmented, dark brown, dark, dark like black, that sort of thing. You want to find your melanoma before it has any capacity to do you in. And one of the nice things, and I mean nice, about melanoma is it is pigmented in the skin, there for you to look at, there for you to recognize as alien and changing and there for you to take to your doctor and have it taken care of before it can do something bad to you. Early melanoma is generally easy to recognize and highly curable.

MODERATOR:
What should we be looking for? And where on the body should we be looking?

GUERRY:
Traditionally melanomas appear where you have had plenty of sun, and so a favorite place is on the back of both men and women, on the particularly lower extremities of women, but in fact there is no place, base, anterior trunk, abdomen, that is immune to melanoma.

The thing to do as an individual is to look at your skin from top to bottom, often with the aid of a friend, companion, partner, spouse, interested individual, once a month, looking for things that are different, odd or changing.

There are these things called the A, B, C, D, Es of melanoma, so what you're looking for is:

  • Something A, asymmetrical . If you were to put a line through the middle of it and then fold it over on itself it wouldn't match up, that's asymmetry.
  • B is for border irregularity . If you look at where this spot ends, it's sort of a jagged line around the outside as opposed to smooth round thing or oval.
  • C is color , and you look for blue black, black, brown -- different hues of brown and black.
  • D is diameter . We talk about a mole or pigmented spot that is bigger than 6 millimeters across, a little bigger than the eraser of a number 2 pencil. That's a spot to pay some attention to.
  • Then a lot of attention has been played to E for evolution -- change or something new. So in particular, a spot which used to be two millimeters and is now six millimeters; a spot that was not present previously and is now there and a month or two has passed and it's still there and bigger. That sort of change, new thing, should be investigated, generally by seeing your primary care doctor or dermatologist.

MEMBER QUESTION:
I am 20 years old and had a mole on my face that the doctor said would likely turn into melanoma if it wasn't removed. I had to go back and get more taken off. He said all of it was gone now. Do I have to worry more about melanoma than most people?

GUERRY:
A good question. Because I don't know what the mole that was taken off looked like under the microscope it's hard for me to give a definite answer.

Quick GuideSkin Cancer Symptoms, Types, Images

Skin Cancer Symptoms, Types, Images

Let's pretend though, that this was an atypical mole, abnormal, dysplastic mole. Then that would mark you as someone a little more likely to get a melanoma over the rest of your lifetime, maybe a twofold chance or if you had lots of big funny moles, maybe a tenfold chance. Remember, this is two times or 10 times a lifetime risk of something like 1 percent, so that would be like a lifetime risk of 2% or 10%. Sounds like a lot, but if you keep your eye on your skin, see your physician once a year and moderate your sun exposure, then the likelihood of getting a melanoma is still pretty small and the likelihood of getting a bad melanoma is very small.

A professional should look at your skin top to bottom and tell you whether you have lots of funny looking moles. If you have a difficult skin examination because you have lots of moles, then consider having photographs taken of your skin by a dermatologist, someone who does skim imaging, and that will help you and your doctor keep an eye on your skin.

MODERATOR:
To establish a baseline?

GUERRY:
That's to establish a baseline, yes, because once you've had a funny mole taken off then you start to pay particular attention to your skin and you begin to think that a number of moles seem to be changing. Then there will be tendency to have many biopsies. You could avoid this by having photographs that assure you there is no change from baseline because melanomas really do change with time and stable spots are very reassuring.

MEMBER QUESTION:
I have had "precancer" spots removed. Are those hot spots for melanoma?

GUERRY:
I suspect that this person is talking about little reddish scaly patches in the skin that sometimes grow up to be common skin cancer -- nonmelanoma skin cancer. These are things called actinic keratoses and 1 in 1000 become the usual kind of skin cancer. These are often treated by dermatologists and primary care physicians with freezing.

"If you have a difficult skin examination because you have lots of moles, then consider having photographs taken of your skin by a dermatologist, someone who does skim imaging, and that will help you and your doctor keep an eye on your skin."

MEMBER QUESTION:
Does lentigo maligna turn into melanoma?

GUERRY:
Lentigo meligna is the earliest form of the kind of melanoma that happens generally in older people who have had a lifetime of plenty of sun. It's melanoma in the very top layer of the skin, the epidermis, and it's melanoma that has no ability to get inside you. If left alone for three years or five years or 10 years or more, it may become bigger and deeper and pose a threat. So it's a form of early melanoma that needs attention, but can't harm you until it's allowed to grow and grow and change.

MEMBER QUESTION:
Is it true that a melanoma can begin inside your body on your internal organs, without any visible moles on the outside?

GUERRY:
It's true, but it's really, really, really rare. It certainly has nothing to do with sunlight. It's a reminder there are some other causes of melanoma. It's also a reminder that melanocytes, the cells that can give rise to melanoma that are in the skin, are also in some other place. These are so rare that no one should be afraid this is going to happen to them.

MEMBER QUESTION:
How can melanoma show up in the vaginal/rectal tissue? My mother was diagnosed with this years ago and succumbed to it. I only thought that melanoma was evident on the skin, but not deep in the body. How does this occur?

GUERRY:
There are melanomas in the back of the eyeballs and in places like the mouth or the inside of the nose or the vagina or the rectum. These obviously have nothing to do with sunlight, are still very rare, and are generally treated with surgery. If they're caught early, just as in skin melanomas, then they're generally cured. They're often found late because you don't tend to peer in your mouth and nose and peer where the sun doesn't shine, but they are so rare that I don't think anyone would advise you check inside your nose, or your mouth or your vagina and so on.

MEMBER QUESTION:
I've had a large mole (brown not dark) on my back for years and years. It's right at my bra line and I have had it taken off once or twice but it always grows back. It's flattish and rough and itches once in awhile but not consistently. I just scratched it and so it has a scab on it right now. Should I have it looked at?

GUERRY:
Yes. It's probably benign, it sounds like it's been looked at under the microscope and reassuringly OK, but because it has grown back and changed I think someone should look at it.

Interestingly, we don't think rubbing moles, physical trauma, having a bra strap over a mole makes them misbehave -- they irritate them but that doesn't make them go from good to bad. I suspect all is well, but I would see the doctor.

MEMBER QUESTION:
My sister had melanoma two years ago on her leg. We used to visit tanning beds a lot. Are tanning beds a major cause of melanoma?

GUERRY:
What we know is that lots of people use tanning beds and that among people who use tanning beds there are more people with melanomas than among people who do not. We also know that tanning beds produce ultraviolet rays that are implicated in making melanomas happen.

What we don't know is whether tanning beds simply mark people as sun worshippers. After all, people who go to tanning beds tend to think tans are beautiful. They tend to maintain a tan, spend time out in the sun, both use tanning beds and go to Florida and lie on the beach.

So, it's very hard to know the extent to which tanning beds make melanomas vs. tanning beds. Tanning salons identify people who are likely to get the kind of sun exposure that makes for more risk of melanoma.

"Melanomas that are in the very top layer of the skin, or that have just broken through to the second layer of the skin."

MEMBER QUESTION:
I am 25 and have had approximately 12 moles removed from my chest, shoulders, back and legs. I am fair skinned and stay out of the sun. When I was younger I spent my summers on the lake.

My dermatologist requires I see her every six months, which is fine but my last appointment she decided not to take any off. All the others have come back abnormal. She said because I have such a variety of moles, and they always come back abnormal, they probably always will be abnormal so keep an eye on them and let her know. I think there is more to it than just that. I guess to me, abnormal is just that, abnormal!

Quick GuideSkin Cancer Symptoms, Types, Images

Skin Cancer Symptoms, Types, Images

Should I see someone else? Is it possible there's more to it than just having several "abnormal" cells? I know cancer can be beat but it is best to catch early. Please advise!

GUERRY:
I think my advice is to find a dermatologist who will, themselves, do photographs of all your skin or send you to a skin imaging center to get photographs done. You should have a copy of those photographs and your physician ought to have a copy or plan to take your photographs into your follow up appointments with your dermatologist. If you have the same old dots and they haven't changed, you don't need a biopsy. If one or more is bigger, darker, different, then I would think of a biopsy.

It's true people who have abnormal moles are more likely to get melanoma, but it's also true they don't need to have all their moles taken off. It's an impossible task, because in part, it's the whole skin that's at somewhat elevated risk of melanoma.

The best plan is to do self-examination aided by high-quality photographs.

MEMBER QUESTION:
Once you have malignant melanoma, what is the likelihood that it will metastasize internally?

GUERRY:
The likelihood of metastases in any group of people goes all the way from tiny to nonexistent, in people with early melanomas. Melanomas that are in the very top layer of the skin, or that have just broken through to the second layer of the skin. For people who have bigger melanomas or later melanomas, melanomas that are into the deeper layer of the skin that are bigger in volume and bigger in diameter, the risk goes from smallish to largish, up to 80% to having metastases some later time.

If you have a melanoma that is more advanced then you're likely to have your lymph nodes examined -- the lymph glands that are nearest to where the melanoma is -- and this is a procedure called a sentinel node biopsy. If the lymph nodes have some melanoma in them it means the disease has gone from where it began to another place and that means the risk of metastasis elsewhere is higher.

MEMBER QUESTION:
What is the recommended treatment for recurrence of melanoma which appears in the lymph node?

GUERRY:
The first thing to do if you have just had one or two lymph nodes taken out is to make the diagnosis of melanoma in the lymph nodes. You then have a lymph node dissection, where the adjacent lymph nodes in the region -- under the arm, for example -- are taken out. You might have involvement of one or two nodes but you would have an additional 15 to 20 nodes taken out to make sure that you have gotten it all. That operation will greatly decrease the likelihood of the disease growing back in that area. And it at least opens the possibility of being cured.

Some people live forever after having involved-lymph nodes taken out, but people with lymph node involvement are more likely than people without to have seeds in their garden elsewhere to sprout at some later time. Therefore, some people with lymph nodes will get adjuvant therapy, or additional therapy, and this might be with a kind of immunological hormone, alpha interferon, or because that doesn't work very well and is fraught with side effects, you might choose to go on a clinical trial of, for example, a vaccine.

MEMBER QUESTION:
My 23-year-old daughter had a mole removed recently in which the pathology report showed a compound melanocytic nevus with severe architectural disorder and recommended a wider excision. Does re-excising "stir up" the possible melanoma cells to spread into other areas?

GUERRY:
Absolutely not -- happily.

When we will re-excise, when we go back and take a very narrow border around an abnormal mole, is when the pathologist tells us two things; one, there is architectural abnormality, and cytological atypia that is severe. So I'm not quite sure what this pathology note means because it only talks about the architecture and doesn't talk about the bricks, whether or not the cells are severely atypical. It would be that that would make us do a narrow re-excision.

So what your daughter is not supposed to have is a cancer operation because she did not have a malignancy. You might consider getting the pathology reviewed by an expert in melanoma and funny moles.

"In families in which something like four or five first-degree relatives -- brothers, sisters, parents and children -- have melanoma, then it's relatively likely that you have a gene or high susceptibility to melanoma."

MEMBER QUESTION:
Since I have had melanomas, I now use a self-tanner. Is this safe for someone who has had melanoma?

GUERRY:
Yes, self tanners are safe and effective. They're not very good sunblocks, so I would continue to use a good sunblock.

MEMBER QUESTION:
I heard that SPF 50 was not any better than SPF 30. Is this true?

GUERRY:
It's not true if you happen to be a very, very fair red-headed freckler. The SPF 50s turn out to be good for the very, very sun sensitive. For the average person you can't really find an appreciable difference between the 50s and the 30s, except they're more expensive.

MEMBER QUESTION:
Can one ever get a safe and healthy tan from the sun or should I just realize that the only safe tan is one from the bottle?

GUERRY:
This is actually a hard question. We evolved on a sunny planet, and the natural response of the skin of sun exposure is to tan.

A tan actually does protect the top layers of the skins from further sun damage, so mild to moderate sun exposure so that at end of the summer you've got some tan, probably means you're a white person who lives on a sunny planet, and does not mean that you've done something stupid. So, being moderate about sun exposure, staying out of the sun between 10 a.m. and 4 p.m., wearing a broad brimmed hat and using a sunblock with a high SPF when you're going to be out in the sun for some time, is prudent.

Living in the basement so you never see a ray of sun isn't good for you, so a little bit of sun exposure is, in fact, just fine.

MEMBER QUESTION:
My father and his mother were both diagnosed with a melanoma that stemmed from a mole. With a strong family history what are my chances of being diagnosed with a melanoma?

GUERRY:
Hard to know. In families in which something like four or five first-degree relatives -- brothers, sisters, parents and children -- have melanoma, then it's relatively likely that you have a gene or high susceptibility to melanoma. It isn't fate; it means you are more likely to get melanoma with a 50-50 chance by age 50.

Quick GuideSkin Cancer Symptoms, Types, Images

Skin Cancer Symptoms, Types, Images

You only have two relatives with melanoma which is compelling from a human perspective but no so compelling from a genetic perspective. Take care of your skin -- don't get sunburned, see a dermatologist and tell him about your family history, get a thorough skin examination, talk about having photographs of the skin which you get a copy of to help you with self-examination and go from there. You should protect your children from getting sunburned and you should tell your brothers and sisters that they should be screened by a dermatologist to have their skin looked at top to bottom.

There's a test for a gene that explains susceptibility to melanoma. I don't think it's worth it, because if you find you have the gene you would do what I just told you; if you find out you don't have the gene you would do what I just told you. It isn't going to change how you manage yourself.

MEMBER QUESTION:
Are new cream treatments available to treat melanoma that work by enhancing the immune system? How successful have they been in early melanoma?

GUERRY:
There are some very interesting cream treatments that probably enhance the response of the immune system and may kill melanoma cells directly. They're still very much under test and I don't advise their use except in the context of a real hard-nosed clinical trial.

It's still best to make the diagnosis with a biopsy and get all the melanoma out with surgery. For the present, my advice is to stay tuned.

MEMBER QUESTION:
What is the latest news on vaccine trials? Are there any new drugs in clinics that seem to be promising?

GUERRY:
There is promise in vaccines. One of the more prominent vaccines, called Canvaxin, is still under testing in people who have had their lymph nodes involved with melanoma. We hope it will turn out to be beneficial but we don't know. In testing of people who had a more advanced stage, stage IV, a piece of melanoma made its way to the lung, was removed and then they received Canvaxin. We know that people who did or did not get the vaccine did just as well, or just as badly -- so we're troubled that in more advanced disease the vaccine seemed not to work. Vaccines are probably going to work in people who have not so much disease, so it might work in stage III, but we just don't know yet.

"The critical thing is to keep an eye on your skin and look for abnormal spots and see the ones that matter and take them to the doctor to make a diagnosis, often by doing a cheap, easy, outpatient biopsy."

There are other trials of vaccine, so I always urge people to talk with their oncologist about the possibility of doing research in the clinical trial so that we can figure out what does work and not waste time giving people things that don't work.

There are lots of interesting things on the horizon, all the way from vaccines to smart therapy that's designed to make up for lost genes or block the action of broken genes. And for the first time in my career, I really do think we might be able to do something important for people whose disease has gotten inside them. It isn't today, probably not tomorrow, it's still off in the future.

The critical thing is to keep an eye on your skin and look for abnormal spots and see the ones that matter and take them to the doctor to make a diagnosis, often by doing a cheap, easy, outpatient biopsy.

MEMBER QUESTION:
My daughter is 16 and has several moles. I have had melanoma. How can I make her understand how important it is to have them checked?

GUERRY:
I would try to find an excuse to get her into the hands and under the eyes of a dermatologist.

With a little luck she has acne and worried about that, so I would suggest that she go with you to the dermatologist to take care of the acne and also to get the skin looked at because sometimes a tendency to get melanoma runs in the family. If she has lovely skin, no acne, I would still nudge her in the direction of a good skin examination. Maybe she's shy and should see a dermatologist that's a woman.

In the big scheme of things, convincing her to look at her skin that's different and alien is another good thing to do. In the larger scheme of things, if you lean on her about the skin, maybe she'll say no but listen to you about not smoking, wearing seat belts and all of those other things which are just as important.

MODERATOR:
Our thanks to DuPont Guerry, MD, for joining us today.



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Reviewed on 7/8/2005 2:05:46 PM

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